Supporting patients when leaving hospital


Discharge to Assess

Discharge to Assess is a national scheme currently being rolled out across the country. It aims to support people to leave hospital as soon as well enough to do so. Bay Health and Care Partners began a pilot implementation of Discharge to Assess in March and the approach is working well. This note updates you on where we are up to and what’s next.

What is Discharge to Assess?

For older people we know that longer stays in hospital can lead to worse health outcomes and can increase their long-term care needs. The last thing they need is to be kept waiting unnecessarily in hospital for an assessment to determine their long term care needs.

2017-12-11 10_05_53-pexels-photo-432722 - Windows Photo Viewer.pngDischarge to Assess aims to ensure that patients who are ‘medically optimised’, and no longer need a hospital bed, are able to leave hospital and have their assessment in the most suitable setting, usually their own home.

When a patient is being discharged from an acute hospital, there are typically four pathways (or routes) that the patient may follow:

0. Patient is able to leave hospital to go home without any additional support, intervention or assessment

1. Pathway 1 (‘Home First’) - for those patients who would benefit from reablement support and / or therapy care input to help them live and manage safely at home

2. Pathway 2 - for those patients who require further rehabilitation in a community setting with short term therapy input

3. Pathway 3 - for those patients who will require 24 hour care in an appropriate care facility

2018-03-12 10_32_23-WELFARE_FGH_007.jpg (2880×1920).png

Discharge to Assess focuses on patients being discharged on pathways 1, 2 or 3, who require further support. It does not apply to patients leaving on pathway 0 who require no further input or support. Patients can also move between pathways to ensure appropriate interventions.

When a patient is identified as needing to follow either pathways 1, 2 or 3; hospital and community staff work closely with social care colleagues to discharge the patient to the most appropriate setting. It is whilst in the most appropriate setting that the person will have an assessment to determine what their needs are to help the person remain living safely in the community.

For people being discharged on Pathway 1, a Hospital Home Care team supports the person being discharged to their own home for an interim, short term period, whilst the assessments are taking place to agree the best interventions needed to allow the person to continue to live safely at home.

What are the benefits of discharge to assess?

shutterstock_73623484.jpgHow is discharge to assess going so far?

Since March a total of 235 patients (as of 28 September) have been able to leave hospital earlier to receive their follow assessment and care in a more suitable environment.

We will continue to keep you updated with regular updates. In the meantime, if you have any questions, please contact Pauline Turner, Discharge to Assess Programme Lead, on More information about discharge to assess can be found at:

Updated November 2018

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